Nicole JohnsonAs a Cardiac Surgery nurse, every now and again your patient comes back with an open chest! It can seem daunting, so let’s talk about it! Less than 5% of cardiac surgery patients come back with an open sternum. Also, in cardiac surgical post-operative patients, most patients will exhibit hemodynamic instability within the first 6 – 12 hours in the ICU so, it is imperative that you are paying close attention to these patients.
What is an open chest?
An open refers to a delay in sternal closure after cardiac surgery to avoid myocardial compression. This avoids decreased cardiac output from impairment of venous return.
A sterile, occlusive dressing, such as Ioban packed with Esmark is usually left over the chest. As a safety reminder: DO NOT put defib pads on the Ioban as the energy can ARC! This creates both a fire risk because of proximity to oxygen, as well as puts your patient at risk of being burned.
Why would your patient’s chest be left open?
- Low cardiac output
- Intractable bleeding
- Myocardial edema
- Arrhythmia
- Cardiac tamponade
- VAD placement
Who is at risk?
- Elderly
- Complicated surgeries such as CABG plus a valve repair/replacement
- Coagulopathies
- Long coronary pulmonary bypass time or cross clamp in the OR
- Pre-operative anti-platelet therapy
- Per-operative MI
Management of patient
- Leave patient in the supine position, however you can gently tilt your patients. Consider using pillows, wedges, or foam for pressure ulcer prevention.
- These patients are commonly intubated and sedated until closure of the sternum.
- Treatment – AGGRESSIVE diuresis to reduce edema.
- The goal is to close the chest within 2 – 5 days.
- If the patient arrests, access the chest and internally massage and defibrillate. This will be managed by the providers.
- At a greater risk for sternal wound infections
Nursing tips for caring for these patients:
- Consider attending an Open-Chest Drill/Simulation to help boost your knowledge and confidence. When you have to open your patient’s chest, it is often very stressful and high pressure, so doing a run through can be so helpful!
- Consider getting your CALS certification – Cardiac Advanced Life Support for patients who have had cardiac surgery. It involves high fidelity simulation training to improve outcomes in patients who have cardiac arrest post cardiac surgery.
- Opening your patient’s chest puts your patient at an increased risk for sternal wound infections.
For more in-depth guidance on caring for cardiac surgery patients, including open-chest management, hemodynamics, complications, and test-focused review, you can explore Nicole’s CSC® Online Course & Book Bundle which includes the on-demand course and Ace the CSC!® Study Guide.
All these resources are designed to boost your knowledge, confidence, and exam readiness, AND they’re on sale now through 12/23!
References:
Postoperative care after cardiac surgery – UpToDate
Intraoperative problems after cardiopulmonary bypass – UpToDate
Surgical management of sternal wound complications – UpToDate
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